Is there a place for forceful-painful manipulation in the management of upper limb CRPS1?

The context is a 30 year old woman, who had a very tight painful plaster cast applied following surgical pinning of her L index finger. Following the removal of her cast at 6 weeks she had immediate relief of her most severe pain followed a few days later by the onset of a swollen, red blotchy hand, stiff -almost rigid finger joints, excessive hair growth, sweating involving her hand and now at three months loss of forearm muscle mass. She has a provisional diagnosis of RSD/CRPS1.

Following referral to a hand surgeon: She has undergone manipulation of her hand under anesthesia X2 and referred for daily physiotherapy that involves a warm wax coating followed by extremely painful, forced fist making -made "just" tolerable by Endone and Oxycontin. The referral letter asked the physio to be "brutal" while mobilizing the hand.

I have three questions:
Is there any evidence to support the use of manipulation under anesthesia of RSD affected hands?

Has repeated, extremely painful, forced manipulation been shown to be useful or otherwise in the above context?

What are the usual physiotherapy modalities used for the treatment of RSD/CRPS1 and are there published clinical trials of the outcomes?

sparty,

I have not read anything on being brutal to the effected limb of an rsd patient. I dont think I would personally like this and would not tolerate this type of treatment from anyone. (this is my opionion)

Being brutal, is not my idea of therapy. I am not having surgery because of the chance it would make my condition worse. I would not allow such treatment of my own body part, as I am in enough pain as it is. I hope some others jump on here with an opinion or two. RSD hurts, I have never heard of anyone on this site being forced into this kind of therapy. I do wish you all the best. I hope you can find proper treatment. ginnie

Regarding pt for RSD/CRPS patients, Dr. Hooshmand stated "no pain is all gain."

http://www.rsdrx.com/pt%20_and%20_crps%20-part%20II.htm

I read with great interest the articles about RSD. I have some of those symptoms. I do have PN for sure. What I want to know is what to do if you really do have injury or structure damage to the foot or ankle so affected. I have a colapsed foot, has alot of pain, and then this PN, or the start of RSD on top of that damaged ankle. It was advised not to fix the foot because of this. I also have had two spinal fussions. Both conditions I have been taking a narcotic for pain in both extremities. Now I read for RSD that isn't so good to do at all. The amount of pain I was in for my neck and ankle both was not tolerable for any quality of life. If I am developing this RSD, what is a person to do when narcotics arn't good for it? These articles didn't say what to do in a case like that. thanks ginnie

ginnie, if there is a serious underlying structural issue, than surgery should be considered. You must have a surgeon that is experienced with RSD. You should probably undergo a block to the surgery site, right before the surgery starts.

Regarding opiates, all things being equal, we're told they're a bad idea, yet many of us have found that they work well for us. Without them, my mobility was worse, and I was constantly guarding my hand. I went through hypnosis with a pain psych doc,.and learned to breath, etc., but the meds made a huge difference for me. We all have to pick our poisons...

Thanks for such a quick reply, I was not expecting that. I really am worried. I saw an orthopedic specialist, yesterday. He said this surgery is huge, and I would be almost a year in recovery. He does not think it is a good idea, or he is uncomfortable doing it because of the neruo symptoms I have. It hurts, but is tolerable with medications. Torns ligaments, colapsed arch, and the heel has to be put back under my foot basically. It requires three seperate incisions, and this same ankle already had two surgeries before, which pre-ceeded these new PN or RSD symptoms. He thinks it would make a painful situation worse in the long run. I may seek a specialist in RSD before all is said and done, somebody who knows alot about it. In the mean time, I will take the meds given. I don't think walking on the foot or the neck would be tolerable without the meds. Lousy position to be in for sure. I will get to a doc. that knows about RSD before any decision is final. Thanks so much for responding to me. ginnie

Thank you for your reply it was a very useful reference.

In the 1980's I headed a benign chronic pain clinic where we dealt with many chronic pain syndromes and we saw quite a few patients with RSD.

However I retired 20 years ago due to CHD and thought that I might have been left behind and that painful manipulation had been shown to be useful.

Back in the 1980's we used a multi-disciplinary approach that included biofeedback, acupuncture, trigger point therapies, re-education of emotion - posture and job task. We found thermography to be a useful tool especially in the context of seeing what normalised the hand temperature... in effect we tuned our therapies using thermography and galvanic skin responses to give us feedback -both in the immediate and longer term.

The Acupuncture techniques we used were taught at the Nanking Municipal Workers Hospital Nanking 1978. Our team included an anesthetist, physiotherapist, masseur, psychiatrist, psychologist and two China trained medical acupuncturists. We followed up most of our patients to gain an understanding of our results.

I would say that the No Pain = Gain in RSD/CRPS1 is a most useful way to express what I feel.